Transcript A Need to Transform the US Health Care System: Improving Access

THE
COMMONWEALTH
FUND
A Patient-Centered Health
System
Karen Davis
President, The Commonwealth Fund
American Hospital Association
Roger Larson Memorial Lecture
May 2, 2006
[email protected]
www.cmwf.org
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Importance of Patient- and FamilyCentered Care
• Important in and of itself – hallmark of
compassion and respect
• Provides feedback to health system on
how to improve care – other industries do
extensive market research
• Improves loyalty, market position, and
reduces malpractice
• Increases trust and adherence
• Improves coordination of care
• Improves clinical outcomes
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Black and Latino Hospital Patients Report
More Problems with Care Experiences
Percent of hospital patients reporting more problems*
in dimensions of patient experiences
White
Black
40
27
30
20
Latino
32
32
21
17
10
10
0
Surgery
Obstetrics
* More problems defined as highest quintile of problem scores in each dimension.
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Source: Adapted from L. S. Hicks et al., “Is Hospital Service Associated with Racial and Ethnic
Disparities in Experiences with Hospital Care?” American Journal of Medicine, May 2005 118(5):529–35.
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Patients who Experience Worse Hospital and
Worse Ambulatory Care Are Twice as Likely to
Report Chest Pain One Year After AMI
Worse hospital &
worse ambulatory care
Worse hospital &
better ambulatory
care
Better hospital &
worse ambulatory
care
Better hospital &
ambulatory care
(comparison group)
0
1
2
Odds Ratio
3
Note: Adjusted odds ratios and 95% confidence intervals of chest pain 12 months after myocardial infarction
(MCI) according to patient experiences with hospital and ambulatory care.
Source: A.M. Fremont, et al., “Patient-Centered Processes of Care and Long-Term Outcomes of Myocardial
Infarction,” JGIM 16 (December 2001): 800-808.
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Patient-Centered Hospitals Are
Associated with Better Outcomes
• Using the Picker
Inpatient Survey,
researchers found
that patients were
more likely to
report lower
mortality and
fewer
complications if
they had received
patient-centered
care
Source: D.L. Bechel, W.A. Myers, and D.G. Smith, “Does Patient-centered Care Pay Off?” Joint
Commission Journal on Quality Improvement 26 (July 2000): 400-9.
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2020 Vision of a Patient- and FamilyCentered Health System
• Superb access, quality, and safety for all
• Patient engagement in care
• Clinical information systems that support highquality care, practice based learning, and
quality improvement
• Care coordination
• Integrated and comprehensive team care
• Routine patient feedback to hospitals and
physicians
• Publicly available information on patientcentered care, clinical quality, efficiency
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COMMONWEALTH
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Geisinger Health System’s Quality
Dashboard – System Level
Safety
Effectiveness
• Discharges without
• Functional status
a reportable incident
• Inpatient mortality
• OSHA-recordable
• Readmissions
workman’s
compensation
cases
Efficiency
Equity
•
Inpatient
satisfaction
(by payor)
Source: Geisinger Quality Dashboard
• Cost per
encounter
• Annualized staff
discharges per
staffed bed
• Average length of
stay
Timeliness
• % of practice sites
meeting their 3rd
available
appointment target
• % of total patient
days with the
patient at the wrong
level of care
PatientCenteredness
• Patient
satisfaction
(by site)
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H-CAHPS – Key Measures to be
Reported
• Composite Measures (number of questions)
– Nurse communication (3)
– Doctor communication (3)
– Cleanliness and quiet of hospital environment (2)
– Responsiveness of hospital staff (2)
– Pain management (2)
– Communication about medicines (2)
– Discharge information (2)
• Overall Rating of Hospital (Q21)
• Willingness to Recommend Hospital (Q22)
Source: Liz Goldstein, “CAHPS Hospital Survey Implementation: Current Status and Next Steps,”
Presentation to the 10th National CAHPS User Group Meeting, March 30, 2006.
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H-CAHPS – Reporting National
Implementation Results
• How?
– Each hospital’s results will be compared to
national and state averages
– Results will be reported for the seven composites
and two overall rating questions
– The user will be able to drill down for more
detailed results
– Each hospital’s results will be adjusted for mode
of data collection, patient-mix, and non-response
bias
– Survey response rates will also be reported
– Results will be updated quarterly
– Results will be integrated with clinical
measures
Source: Liz Goldstein, “CAHPS Hospital Survey Implementation: Current Status and Next Steps,”
Presentation to the10th National CAHPS User Group Meeting, March 30, 2006.
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What Patients Say About their Experiences
with Hospital Care
Always
Usually
Never
75
Communication with nurses
19
81
Communication with doctors
58
Communication about medications
7
14 6
17
26
Responsiveness of hospital staff
61
25
14
Cleanliness and quiet of hospital environment
61
24
15
70
Pain management
Rating of hospital (9-10, best; 7-8, medium; 0-6, worst )
32
71
yes, definitely/probably no)
20%
40%
8
21
56
Willingness to recommend (Definitely yes, probably
0%
21
79
Discharge information (yes/no)
10
12
23
60%
Source: AHRQ/CAHPS, CAHPS Hospital Survey Chartbook: What Patients Say about their
Experiences with Hospital Care, March 2006. Prepublication Copy.
80%
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100%
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National Variation in Problem Scores
by Hospital Type
Academic
Health
Center
13.2
Teaching
Hospital
22.9
10.2
NonTeaching
Hospital
22.1
8.6
0.0
11
16.7
10.0
Range
20.0
30.0
Median
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Source: Paul D. Cleary and Susan Edgman-Levitan
Center for Shared Decision-Making
Dartmouth-Hitchcock Medical Center
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• Provides tools to assist
with health care decisions
(e.g., videotapes, booklets,
websites)
• Provides follow-up
counseling with skilled staff
• Seeks to be a prototype for
health care systems
nationwide
Kate Clay, BA, MSN,
Program Director
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COMMONWEALTH
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Advanced Practice Nurse Transitional Care
Model Improves Patient Outcomes and
Decreases Health Care Costs
•
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Innovative model of care coordination delivered by
advanced practice nurses (APNs)
–
Focuses on older adults making difficult transition from
hospital to home and at risk for poor outcomes
•
Team from University of Pennsylvania, Aetna Corporation,
and Penn Home Care and Hospice promoting widespread
adoption
•
Examining effectiveness of APN Model with a high-risk
Medicare managed care population in the mid-Atlantic
region who are referred for telephonic case management
•
Enrollment:
–
48 Aetna members enrolled in a large scale
evaluation of the APN Model as of March 31, 2006
Source: Mary Naylor, Project Update to The Commonwealth Fund, April 2006.
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Transitional Care Reduces
Rehospitalization for Heart Failure Patients
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Resource use among congestive heart failure patients ages 65+ treated at
six Philadelphia hospitals during 1997–2001 who were randomly assigned
to receive a three-month transitional care intervention or usual care
Usual care group
100
200
$16,000
162
80
$12,481
150
61
60
Intervention group
48
$12,000
104
100
$8,000
50
$4,000
0
$0
40
20
0
Percentage of patients who
were rehospitalized or died
Number of
hospital readmissions
$7,636
Average cost of care
Source: Medical records and patient interviews (N=239) (Naylor et al. 2004), S. Leatherman
and D. McCarthy, Quality of Health Care for Medicare Beneficiaries: A Chartbook, 2005,
The Commonwealth Fund. www.cmwf.org/usr_doc/MedicareChartbk.pdf.
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Care Transitions Measure (CTM)
• Developed by Dr. Eric Coleman at
University of Colorado Health Sciences
Center
• Current project aimed at showing how a
patient centered measure can drive
quality
• Under review at National Quality Forum
• High demand – 450 requests for
permission
• At least 10 QI projects are using the
measure
E.A. Coleman, “Windows of Opportunity for Improving Transitional Care,” Presentation to The
Commonwealth Fund Commission on a High Performance Health System, March 30, 2006.
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CTM-3 Items
• When I left the hospital, I had a good
understanding of the things I was
responsible for in managing my health
• When I left the hospital, I clearly
understood the purpose for taking each
of my medications
• The hospital staff took my preferences
and those of my family or caregiver into
account in deciding what my health care
needs would be when I left the hospital
E.A. Coleman, “Windows of Opportunity for Improving Transitional Care,” Presentation to The
Commonwealth Fund Commission on a High Performance Health System, March 30, 2006.
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Care Transition Measure Scores, Emergency
Department Use and Hospital Readmissions
Emergency Department Use
Hospital Readmissions
69
69
68
68
p=0.01
67
66
65
65
64
64
63
63
62
62
61
61
60
60
Yes
p=0.04
67
66
No
17
No
E.A. Coleman, “Windows of Opportunity for Improving Transitional Care,” Presentation to The
Commonwealth Fund Commission on a High Performance Health System, March 30, 2006.
Yes
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Veterans Health Administration
Source: Charles Humble, Jim Schaefer, and Barbara Fleming, “Measuring the Patient’s Experience
of VA Health Care,” Forum, November 2004. Accessed through www.academyhealth.org
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COMMONWEALTH
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Heart Failure Patients Given Written Instructions
or Educational Materials When Discharged, 2004
Percent of heart failure patients discharged home with written
instructions or educational material*
100
87
80
60
64
50
60
49
33
40
20
26
9
0
National
Average
Top 10 %tile
Hospitals
Bottom 10
%tile
Hospitals
Top 10%
States
Top 25%
State
Median
Bottom 25% Bottom 10%
States
States
*Heart failure patients discharged home with written instructions or educational material given to patient or care giver
at discharge or during the hospital stay addressing all of the following: activity level, diet, discharge medications,
follow-up appointment, weight monitoring, and what to do if symptoms worsen.
SOURCE: Hospital Compare, CMS, http://www.hospitalcompare.hhs.gov
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COMMONWEALTH
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Managing Chronic Conditions at
Cincinnati Children’s Hospital
• Patients and families
become part of the team
• Visioning perfect care
• Family perspective
• Health care team
• Increasing the urgency for
change
• Transparency
• Family Preference Card
• Includes information on
families’ and patients’
preferences for
documenting on chart
and participating in
rounds
Source: Maria T. Britto, “Improving Care for Children with Chronic Conditions at Cincinnati Children’s
Hospital: Cystic Fibrosis and Beyond,” Presentation at Pennyhill Park Meeting, July 15, 2005
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Policies to Promote Patient-Centered Care
• Public reporting
• Pay for performance
–
–
–
–
Clinical quality
Patient-centered care
Efficiency across acute care episodes
Premier experience
• Coverage of shared decision making and
translation services
• Coordination of care standards and payment
reform
• Information technology
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COMMONWEALTH
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Thank You!
•
Stephen C. Schoenbaum, M.D., Executive Vice President
and Executive Director, Commonwealth Fund
Commission on a High Performance Health System
•
Anne-Marie J. Audet, Vice President, Commonwealth
Fund, Quality and Efficiency Program
•
Melinda K. Abrams, Senior Program Officer,
Commonwealth Fund, Child Development and Preventive
Care Program and Patient-Centered Primary Care
Initiative
•
Alyssa L. Holmgren, Research Associate,
Commonwealth Fund
Visit the Fund at: www.cmwf.org
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COMMONWEALTH
FUND